ETCare: a randomized, controlled, masked trial comparing two solutions for upper airway care in the NICU

BACKGROUND

Small quantities of normal saline are sometimes instilled into the endotracheal tube of intubated neonates, to assist with the removal of thick secretions and maintain patency of the endotracheal tube. However, saline is detrimental to the innate immune system of the upper airway mucosa, rapidly unfolding and inactivating antimicrobial peptides such as LL-37. We previously reported the preparation and feasibility testing of 'ETCare', a low-sodium, physiologically based solution for airway care, and we now report results of a randomized, masked, controlled, two-centered study testing ETCare vs sterile saline among 60 intubated NICU patients.

STUDY DESIGN

Sixty intubated NICU patients were randomized to having their airway care with ETCare vs saline. Three hypotheses were tested: (1) tolerance - patients will tolerate ETCare for airway care as well as they tolerate saline, (2) nosocomial infections - ETCare will result in fewer tracheal aspirates where organisms grow and fewer cases of nosocomial sepsis, and (3) chronic lung disuse - ETCare will result in fewer patients discharged home on supplemental O2.

RESULTS

Thirty NICU patients with an endotracheal tube in place were randomized to receive their airway care with ETCare, and 30 to receive their care with saline. Only the pharmacist was aware of the randomization; the two solutions were visually indistinguishable and were dispensed in identical syringes. Tolerance of the solutions was similar. The ETCare recipients had trends toward fewer positive blood cultures (odds ratios (OR), 0.48; 95% confidence interval (CI), 0.13 to 1.68), and fewer discharges home on supplemental O2 (OR, 0.43; 95% CI, 0.14 to 1.32; P=0.075).

CONCLUSIONS

On the basis of this study and our previous 10-patient feasibility trial, we maintain that, for airway care, intubated NICU patients tolerate ETCare as well as saline. Data from this study can be used in estimating the sample sizes needed for a phase III trial. We speculate that such a trial will demonstrate that, compared with saline, ETCare will result in fewer nosocomial infections and less chronic lung disease.

Avoiding endotracheal intubation of neonates undergoing laser surgery for retinopathy of prematurity

OBJECTIVE

Respiratory support of neonates during and following laser surgery for retinopathy of prematurity (ROP) is commonly accomplished using endotracheal intubation and mechanical ventilation. However, most patients undergoing ROP surgery have been weaned off mechanical ventilation days or weeks before the surgery. When they are electively re-intubated for ROP surgery, it can be difficult to extubate them postoperatively. One of the three level III neonatal intensive care units (NICUs) in the Intermountain Healthcare system initiated a program of using nasopharyngeal prongs, rather than endotracheal intubation, for respiratory support during ROP surgery.

METHODS

We performed an historic cohort analysis of all neonates undergoing ROP surgery during their NICU stay at the three level III NICU's between 1 January 2002 and 31 March 2006. Data collected included birth weight, gestational age at delivery and corrected gestational age at ROP surgery, whether or not they were intubated in the days immediately preceding the ROP surgery, whether or not they were electively intubated for the ROP surgery, the respiratory modality used during and the 3 days following ROP surgery, and all blood gas determinations and respiratory charges during this period.

RESULTS

Fifty-four patients underwent ROP surgery during this period. All 23 from NICUs 'A' and 'B' had endotracheal intubation for surgery, while in NICU 'C' 24 were managed using nasopharyngeal prongs. The birth weights of those intubated for surgery (661+/-180 g, mean+/-s.d.) were similar to those not intubated (732+/-180 g). Similarly, the gestational age at birth did not differ between those intubated for surgery (25.2+/-1.3 week) and those not (25.6+/-2.1 week). The day following surgery, 77% (23/30) of those who had been intubated for surgery remained intubated and on mechanical ventilation, whereas only one (4%) of those not intubated for surgery was intubated in the postoperative period (P<0.001). On day 3 following surgery, 50% (15/30) of those intubated for surgery remained intubated and on mechanical ventilation, whereas none of those not intubated for surgery were intubated (P<0.001). Management with nasopharyngeal prongs did not result in higher PCO(2)s, or lower pH values, during or after surgery. Respiratory charges for the 3 days following surgery were 1762+/-678 dollars (mean+/-s.d.)/patient among those intubated versus 357+/-352 dollars/patient for those managed with nasopharyngeal prongs (P<0.001).

CONCLUSIONS

Neonates undergoing laser surgery for ROP can often be supported intraoperatively and postoperatively using nasopharyngeal prongs, thus avoiding the need for endotracheal intubation.

Comparing two methods of delivering high-flow gas therapy by nasal cannula following endotracheal extubation: a prospective, randomized, masked, crossover trial

OBJECTIVE

We compared two methods of delivering high-flow gas therapy by nasal cannula, applied immediately after planned endotracheal extubations of NICU patients.

STUDY DESIGN AND METHODS

Thirty NICU patients who were about to be extubated from mechanical ventilation were randomized into two groups; Group 1 received Vapotherm for the first 24 h after extubation, then standard high-flow nasal cannula for the next 24 h, and Group 2 received standard high-flow therapy for the first 24 h, then Vapotherm for the next 24 h. At 24 h after extubation and again 48 h after extubation, a neonatologist who was not aware which modality the patient had been receiving examined the nasal mucosa and applied a scoring system. A research nurse who was unaware of the modality abstracted respiratory rates and respiratory effort scores from a specific study-bedside record. The experimental design was such that a patient could 'fail' extubation either by reintubation for mechanical ventilation, or by rescue to the opposite modality before completing the 24-h test period.

RESULTS

Fifteen patients were randomized to Group 1 and 15 to Group 2. No differences were apparent between the groups in birth weight, gestational age, age at study entry, gender or underlying pulmonary disorder. Respiratory rates were similar while on Vapotherm (52+/-13 breaths/min, mean+/-s.d.) and high-flow (54+/-14/min). At 24 h after starting the modality, those on Vapotherm had more normal examinations of the nasal mucosa (2.7+/-1.2 vs 7.8+/-1.7, P < 0.0005) and lower respiratory effort scores (1.2+/-0.6 vs 2.0+/-0.9, P < 0.05) than did those on high-flow. No patients failed while on Vapotherm, but seven failed while on high-flow (two reintubations and five rescue switches to Vapotherm, P < 0.005).

CONCLUSIONS

Among NICU patients immediately following extubation, Vapotherm performed better than a standard high-flow nasal cannula in maintaining a normal appearing nasal mucosa, a lower respiratory effort score, and averting reintubation.